Acknowledgement: I have answered these questions to the best of my knowledge and understand the information presented to me. I have also informed the technologist that at this time I am pregnant OR NOT pregnant (circle).
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Patient/Parent/Legal Guardian Signature
Clinician Providing Contrast Coverage:
Lot #:Expiration Date:
Patient Discharge Instruction Given:
Discharge Instruction for Contrast Extravasation Given:
You have the right to be informed about the recommended diagnostic procedure to be used, so that you may make the decision whether or not to undergo this procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you. It is so that you can choose to give or withhold your consent to the procedure.
If you are pregnant or think you may be pregnant, please inform center personnel at once. It is very important that you inform the technologist if you have a heart valve, a pacemaker, aneurysm clips, or other implanted metal or electrical devices.
Your physician has requested a magnetic resonance imaging (MRI) examination to obtain additional information. MRI uses a magnetic field and radio waves to produce images of the body part being examined. MRI does not use x-rays or radiation and is painless. Some scanners may produce loud repetitive noises throughout the procedure therefore, headphones or earplugs will be provided.
A contrast may be injected as part of your MRI to provide better images of the part of the body being examined.
Potential Risks: The following complications are possible anytime an injection is given: potential for pain, bleeding, bruising or swelling at the injection site. MRI exams requiring contrast may result in: mild headache, nausea, itching or other vague symptoms for a short time after the injection.
Additional allergic reactions in response to the contrast agent may include: hives, shortness of breath or difficulty in swallowing. There have been rare instances of death after the administration of the contrast agent. It is very important that you inform the technologist if you experience any of the conditions mentioned in this form.
If you have previously had a reaction to a contrast injection such as hives, shortness of breath, any significant reaction requiring hospitalization, a history of asthma or other allergic conditions, any history of anemia, sickle cell anemia or kidney disorder; or if you are breastfeeding you must inform the technologist. The safety of contrast in children under 2 has not been established.
The diagnostic test being performed was ordered by your physician based on your symptoms and condition. The benefits of this exam are to assist your physician with a diagnosis.
I (WE) CERTIFY THIS FORM HAS BEEN FULLY EXPLAINED TO ME, THAT I (WE) HAVE READ IT, OR HAVE HAD IT READ TO ME (US), THAT THE BLANK SPACES HAVE BEEN FILLED IN AND THAT I (WE) UNDERSTAND ITS CONTENTS. I (WE) HAVE SUFFICIENT INFORMATION REGARDING THE PROCEDURE(S) AND THE RISKS AND HAZARDS INVOLVED.
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Witness Name Printed: